Understanding Stillbirth and the Investigations Involved
Every day, about six babies are stillborn in Australia, marking an incredibly difficult time for families. The question of why a baby died often lingers in the minds of parents, yet for one in three stillbirths, there is no clear answer. This lack of information can be due to insufficient investigation. As a perinatal pathologist, I am part of a team that works to determine the cause of a stillbirth, assess the risk of recurrence in future pregnancies, and explore what might be done differently next time.
The Role of the Placenta in Investigation
The placenta serves as a diary of the pregnancy and plays a crucial role in investigating a stillbirth. In Australia, a stillbirth is defined as the death of a baby in the womb at 20 or more completed weeks’ gestation, or a birthweight of 400 grams if the gestation is unknown. Examining the placenta involves a visual inspection, weighing and measuring it, and identifying any abnormalities that may have contributed to the baby’s death.
This process includes looking at the size of the placenta relative to the baby’s age and checking for signs such as large blood clots. The visual inspection guides the collection of small samples for microscopic examination. Additional samples may be sent to the lab to check for infections or genetic causes of the stillbirth. If desired, the placenta can be returned to the family after testing.
The placenta is considered the most useful investigation in understanding stillbirth. Abnormal changes in the placenta have been reported in 23–96% of stillbirths, depending on various factors.
What Is an Autopsy?
An autopsy, also known as a postmortem, is a medical procedure performed by perinatal pathologists to investigate the cause of a stillbirth. It is conducted with the same care as an operation on a living baby. An autopsy can identify a cause of death in 16–42% of stillbirths. Even when no specific cause is found, the information gathered can provide valuable insights into what did not contribute to the stillbirth.
The investigations carried out during an autopsy depend on the family’s wishes and require their consent. This is a legal, voluntary, and informed process. The next of kin, usually the mother, receives written information and has the opportunity to discuss the extent of the investigations with her doctor or midwife.
Types of Autopsies and Investigations
There are several types of autopsies and investigations:
Full Autopsy
This involves reviewing the clinical history and maternal investigations, examining the external and internal features of the baby, and treating the baby with utmost respect. A surgical incision is made to examine organs such as the heart, lungs, liver, and kidneys. Small samples may be taken for microscopic analysis. The skin incision is stitched and covered with a dressing so it cannot be seen when the baby is dressed. If necessary, a surgical incision on the scalp may be made to examine the brain. Swabs and other samples may be taken to look for infection, genetic, or metabolic issues.Limited Autopsy
This focuses on examining one region of the baby, such as the brain or heart.Minimally Invasive Autopsy
This involves taking a sample of a specific organ using a small needle without making surgical incisions.External Examination
This includes measurements, external photographs, and a close examination of the baby’s external features. Radiology, such as X-rays or MRI, may be part of this examination.
What Happens Next?
After an autopsy, a report is prepared by the perinatal pathologist, which typically takes six to 12 weeks to complete. This report synthesizes all the information gathered from the autopsy and other investigations. A multidisciplinary team reviews the findings, which guide discussions with the parents, provide learning points for the care team, and help inform future pregnancies. Parents receive a copy of the report.
Families can choose to see, touch, and hold their baby after an autopsy. Perinatal pathologists work closely with families to support their cultural needs and sensitivities related to the examination of their baby and the placenta.
Perinatal pathologists aim to uncover the truth and provide answers. Our work is driven by warmth and kindness, even though we face the reality of loss daily.
If this article raises concerns for you or someone you know, contact the Red Nose 24/7 Grief and Loss Support Line on 1300 308 307 or visit the Red Nose website for information and support.
Jane Dahlstrom is affiliated with the Centre of Research Excellence in Stillbirth and the Royal College of Pathologists of Australasia. She is an honorary anatomical pathologist at ACT Pathology, Canberra Health Services.
